Provider Demographics
NPI:1063472017
Name:GJERTSON, CARL K (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:K
Last Name:GJERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:UROLOGY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-6227
Practice Address - Country:US
Practice Address - Phone:860-679-4100
Practice Address - Fax:860-679-1390
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0451712088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1063472017Medicaid
CT1063472017Medicaid
CT340000407Medicare PIN